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1 . SEWAGE <br /> Distance to Public Sewers Connection necessary: Yes `No_ <br /> Does existing septic system comply with Ord. #549 : Yes_ No_ <br /> Unknown If no, explain: <br /> Describe septic installation to be installed: <br /> Ise <br /> 2 . MATER SUPPLY <br /> Is water supplied by private well : Yes No Is well proper: <br /> Ye1s>- No State deficiency: <br /> Does, existing or porposed use make this well public water: Yes <br /> No--- Sample of well water taken: Yes No Date taken <br /> Results Additional information or comments <br /> 3 . GARBAGE & REFUSE <br /> . Licensed scavenger pick-up: Yes No Service Area No. <br /> Other proposed disposal method: <br /> Potential problem: <br /> 4. FLY. MOSQUITO OR VECTOR EOTENTIAL <br /> State possible vector potential & necessary control: <br /> 5 . TOILET/BATH FACILITES <br /> No. & location existing : Additional <br /> facilities needed _ <br /> 6 . PREVIOUS OPERATION HISTORY <br /> 7 . GENERAL SANITATION <br /> State any problems not previously noted : .--, <br /> 6 . POPULATION DENSITY <br /> Appx. No . People per sq. mi . — <br />